Article Text

Original research
Barriers and facilitators to implementation of shared medical appointments in primary care for the management of long-term conditions: a systematic review and synthesis of qualitative studies
  1. Fiona Graham1,
  2. Mei Yee Tang1,
  3. Katherine Jackson2,
  4. Helen Martin3,
  5. Amy O'Donnell1,
  6. Oladapo Ogunbayo4,
  7. Falko F Sniehotta1,5,
  8. Eileen Kaner1
  1. 1NIHR Policy Research Unit in Behavioural Science, Newcastle University, Newcastle upon Tyne, UK
  2. 2Department of Sociology, Durham University, Durham, UK
  3. 3Research and Evidence Team, NECS, Newcastle upon Tyne, UK
  4. 4Population Health Science Institute, Newcastle University, Newcastle upon Tyne, UK
  5. 5Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
  1. Correspondence to Dr Fiona Graham; fiona.graham{at}newcastle.ac.uk

Abstract

Objective To synthesise the published literature on practitioner, patient and carer views and experiences of shared medical appointments (SMAs) for the management of long-term conditions in primary care.

Design Systematic review of qualitative primary studies.

Methods A systematic search was conducted using MEDLINE (Ovid), PsycINFO (Ovid), CINAHL (EBSCOhost), Web of Science, Social Science Premium Collection (Proquest) and Scopus (SciVerse) from database starting dates to June 2019. Practitioner, patient and carer perspectives were coded separately. Deductive coding using a framework approach was followed by thematic analysis and narrative synthesis. Quality assessment was conducted using the Critical Appraisal Skills Programme for qualitative studies.

Results We identified 18 unique studies that reported practitioner (n=11), patient (n=14) and/or carer perspectivs(n=3). Practitioners reported benefits of SMAs including scope for comprehensive patient-led care, peer support, less repetition and improved efficiency compared with 1:1 care. Barriers included administrative challenges and resistance from patients and colleagues, largely due to uncertainties and unclear expectations. Skilled facilitators, tailoring of SMAs to patient groups, leadership support and teamwork were reported to be important for successful delivery. Patients’ reported experiences were largely positive with the SMAs considered a supportive environment in which to share and learn about self-care, though the need for good facilitation was recognised. Reports of carer experience were limited but included improved communication between carer and patient.

Conclusion There is insufficient evidence to indicate whether views and experiences vary between staff, medical condition and/or patient characteristics. Participant experiences may be subject to reporting bias. Policies and guidance regarding best practice need to be developed with consideration given to resource requirements. Further research is needed to capture views about wider and co-occurring conditions, to hear from those without SMA experience and to understand which groups of patients and practitioners should be brought together in an SMA for best effect.

PROSPERO registration number CRD42019141893.

  • general medicine (see internal medicine)
  • health services administration & management
  • primary care
  • qualitative research

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. As this study is a systematic review, all data reported has been previously published and is in the public domain.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Strengths and limitations of this study

  • Focus on qualitative evidence provides rich insights into barriers to implementation of shared medical appointments (SMAs) in primary care from the perspectives of practitioners, patients and carers.

  • Robust search strategy, based on previous high-quality reviews, refined to allow us to better identify qualitative research.

  • The thematic synthesis approach has enabled the identification of analytical themes that offer a new interpretation of practitioner and patient experiences of SMAs beyond earlier reviews.

  • Rapidly evolving area of practice and publications and the most recent evidence may be missing.

  • Grey literature was excluded from the synthesis

Introduction

Over 15 million people in England are living with one or more long-term conditions.1 Such multimorbidity is more prevalent in those over 65 years and in socioeconomically deprived areas.2 3 Long-term conditions require ongoing disease management and care, which consume a significant amount of healthcare service delivery time.4 Models of care that support patient self-management (or self-care) are at the centre of government policies worldwide,5 including NHS plans.6 7 Shared medical appointments (SMAs) or group consultations have been promoted as a new way of delivering primary care to simultaneously improve patient self-management and resource use efficiency.8 9

SMAs typically involve a group of patients with the same long-term condition(s) meeting with one or more healthcare practitioners. In contrast to group education programmes, the SMA usually replaces a 1:1 appointment and may include physical examinations, medication adjustments or other clinical interventions.8 10 It has been theorised that SMAs may improve patient self-efficacy by enabling participants to witness the consultation experiences of others and to observe disease management strategies of peers who act as realistic role models for their own self-care.4 10 While there is some evidence that SMAs can support self-management of long-term conditions,4 it is important to understand the feasibility and acceptability of implementing SMAs from the perspectives of primary healthcare practitioners, patients and carers to ascertain if this model of care can meet their needs and reduce health inequalities.

It has been reported that practitioners enjoy SMAs, citing benefits including development of team relationships, learning from patients and more variety in work.4 10 Patients attending SMAs have also reported feelings of socialisation or normalisation of a condition, increased trust with healthcare practitioners and enhanced knowledge.4 11 However, a small number of studies have reported patient concerns, including confidentiality and being unclear about the purpose of a session.4 Providers have reported concerns around insufficient clinician and group facilitation training for SMAs and the need for suitable premises.4 11 12 Earlier reviews have focused on secondary care,4 which is typically disease-specific with time-limited follow-up after specialist treatment.11 In contrast, primary care has an emphasis on ongoing disease management, often including multiple conditions, and care continuity. Hence, this systematic review of qualitative research aimed to provide an in-depth insight into the experiences and perceptions of SMAs for the management of long-term conditions in primary care, including identifying barriers and facilitators regarding implementation.

Review research questions:

  1. What are patient and practitioner views and experiences of SMAs in primary care?

  2. Do these views and experiences vary by long-term condition and/or other patient/ practitioner characteristics?

  3. What does the literature tell us about potential barriers and facilitators to the delivery and uptake of SMAs in primary care?

Methods

A systematic review and narrative synthesis of qualitative studies was conducted.

Search strategy and selection criteria

We searched MEDLINE (Ovid), PsycINFO (Ovid), CINAHL (EBSCOhost), Web of Science, Social Science Premium Collection (Proquest) and Scopus (SciVerse) from database start dates to June 2019. A combination of keywords and Medical Subject Headings to locate relevant qualitative studies were used (see online supplemental file 1). Database searches were supplemented by forward and backward citation searches of the included papers.

Primary qualitative studies were included that (1) explored the views of primary healthcare practitioners, staff, patients or carers that had been involved in the delivery of or attended SMAs within primary care; (2) met our criteria to be classed as an SMA (group appointments that were intended to replace standard 1:1 appointments in general practice, were delivered by primary care practitioners, and included clinical advice and management as well as peer learning and support); and (3) had a patient population with at least one long-term condition. For studies in which participants delivered/attended SMAs for both long-term conditions and non-long-term conditions, only data relating the former were extracted and synthesised. Papers were excluded if (1) the group session did not include an individual assessment/examination/consultation with a primary healthcare professional; (2) papers reported survey data only; and (3) it was not possible to differenciate between data collected from participants attending SMAs for long-term conditions those attending SMAs for non-long-term conditions (eg, antenatal care).

The title and abstracts of retrieved citations were double-screened, and where there were discrepancies, screeners met to reach agreement. All studies at the full-text stage were similarly double-screened with any uncertainties resolved by discussion with a third member of the review team.

Quality assessment

Methodological quality of eligible studies was assessed by two independent reviewers using the Critical Appraisal Skills Programme (CASP) checklist for qualitative studies.13 This was done to assess conduct (validity and robustness), transparency, content and utility of findings. Studies were not excluded on the basis of this appraisal, as limited reporting is not necessarily indicative of low-quality research and risks the exclusion of appropriate studies.14 The strengths and limitations of each included study were considered during the analysis to ensure that findings from unreliable studies did not unduly influence our results.15

Data extraction and synthesis

Key characteristics of the included studies and study participants were recorded using a data extraction form, with the extracted data double-checked by another team member. Full-text papers were then imported into NVivo V.12. A framework based on themes previously identified by reviews4 10 was used to deductively code participant quotes and authors’ interpretations in the Results and Discussion sections of the studies. All data were coded by one reviewer then checked by a second. Data reflecting the views of practitioner, patients and carers were analysed separately.

Data excerpts were compared and contrasted, and descriptive themes were formed by merging codes and grouping them around existing themes4 and emerging themes. This included condensing the existing themes into related/discordant subthemes which were subsequently translated into higher-level themes to better answer the research questions. Texts were reread and data recoded according to newly structured thematic framework through an iterative process to ensure these themes best reflected the data. Data excerpts were then examined to look for similarities and differences in the perspectives of practitioners or patients by characteristics (eg, gender and age).

The Enhancing Transparency in Reporting the Synthesis of Qualitative Research checklist was used for reporting this review (see online supplemental material).

Patient and public involvement (PPI)

The proposed programme of SMA research was presented to a PPI panel who provided their views and opinions about what potential barriers and facilitators to attending an SMA might be from a patient perspective, thus providing insights into potential findings of the review. Our affiliated PPI group read and commented on the draft of this article and have identified several patient community groups through which to share a lay summary of the research findings.

Results

Figure 1 outlines the screening and selection process resulting in the inclusion of 18 studies in the final synthesis.

Figure 1

Flow diagram of review search. Our search resulted in the retrieval of 84 papers for full-text review. Of these, 66 were ineligible for inclusion. Three additional studies were identified following forward and backward citation searches. This resulted in the inclusion of 18 studies in the final synthesis. SMA, shared medical appointment.

Quality appraisal

Quality of the included studies was generally high; most papers met the majority of the CASP checklist criteria (online supplemental file 2). Weaknesses commonly related to lack of information about participant recruitment16–22 and researcher reflexivity, which was missing in all but two studies.23 24

Overview of included studies

Studies were published between 2004 and 2018 and are summarised in table 1. Studies report the views and experiences of a total of 262 practitioners, 306 patients and 39 carers. The majority of studies were from North America; two were from Australia. Only two studies looked at the views of those healthcare professionals who were not delivering SMAs22 25; the rest of the studies reported the views of individuals with experience of having delivered/attended SMAs. One study26 involved video SMAs; all others were face to face. One study focused on an SMA for children.16

Table 1

Overview of studies and participant characteristics

The healthcare practitioner views most commonly reported were general practitioners (GPs), family physicians, practice nurses and nurse practitioners (NPs).16 18 19 21 24 25 27–31 Fewer studies captured the views of healthcare managers, programme/research coordinators and administrators.18 21 23 28–31

The SMAs varied in terms of content, duration, numbers of attendees and frequency of sessions. The majority of studies focused on single-condition SMAs (n=12); three reported on both single-condition and mixed-condition SMAs29 31 32; two reported on mixed-condition SMAs only27 33; and one gave no details.25 ‘Mixed-condition’ SMAs were for patients with one or more of a number of different conditions and thus included those with one condition and those with multimorbidity. Studies of SMAs for diabetes were most common (n=15). A summary of the SMAs is given in table 2.

Table 2

Characteristics of SMAs delivered in reviewed studies

Narrative synthesis

Tables 3 and 4 present the findings of the analysis of practitioner and patient perspectives, respectively. Each table outlines examples of codes that were used to group the data into subthemes, which were subsequently translated into higher-level themes. Practitioner themes were ‘advantages and benefits’, ‘barriers and challenges’ and ‘implementation success and sustainability’.

Table 3

Views and experiences of practitioners and staff

Table 4

Views and experiences of patients and carers

Advantages and benefits

Comprehensive patient-led care

Practitioners viewed the care delivered via SMA to be more comprehensive25 29 31 and better suited to supporting self-management than 1:1 appointments.18 Longer appointment times enabled a range of issues and concerns to be covered in the one session18 22 25 and provided the opportunity for patients and practitioners to develop a care plan together.18 29 31 Practitioners reflected that the group sessions had improved their own practice as they were able to gain further insights into patient circumstances, their conditions and the challenges to self-management that patients face in their daily lives.16 25 27–29 Practitioners believed the presence of multiple clinicians with complementary expertise in the SMAs enabled more holistic care.23

Peer support and accountability

Practitioners valued the peer support afforded to patients by group appointments,19 23 28 30 31 believing patients benefitted from listening to the experiences of their peers and from hearing responses to other participants’ questions.22 This, in turn, helped them to understand their condition better and how best to manage it.19 23 Practitioners said patients were able to relate to each other, which helped to normalise their conditions16 and provide confidence in self-management.17 Some clinicians explained there was ‘cathartic value’ or ‘therapeutic effect’ from patients sharing with others in the group their personal story of disease management.16 21 29 The group format also enabled collective problem solving with clinicians and peers.31 Two studies also reported that practitioners believed that patients felt accountable to other group members, which increased their motivation to reach their self-set goals.28 29 However, a clinician in another study reported that the peer-to-peer support element of the SMA ‘didn’t work very well’ when two patients were paired together who were both ‘non-compliant’ and ‘didn’t give off the best information’.28

Efficiency and lower cost

Clinicians reported that they found the sessions enjoyable and made their work less repetitive,21 22 28 less rushed and more relaxed.21 GPs and other managerial staff perceived SMAs to be more time efficient and cost-effective than usual 1:1 appointments19 28 31 and improved patient access to healthcare.28 31 The multidisciplinary nature enabled them to get ‘a lot of work done’23 and meet evidence-based guidelines.31 However, nursing staff did not report time and cost efficiencies; rather they described the additional time and resources involved in setting up the SMAs.

Barriers and challenges to adoption and implementation

Patient resistance and suitability

NPs without SMA experience had concerns about recruitment and attendance, as patients were ‘historically’ and ‘culturally’ accustomed to receiving 1:1 care.25 They also expressed concerns over the appropriateness of group sessions for some patient population groups, particularly those with ‘concurrent disorders that ‘can’t keep to the timeline or sit long enough’.25 Lack of motivation to improve health21 and reluctance to share information in a group setting were perceived reasons why patients may not attend SMAs. Concerns about the ability to maintain patient confidentiality during the group session were raised but ‘lessened when it was explained that this is dealt with through a signed confidentiality agreement’.21 22

Practitioners with SMA experience reported that the top barrier to implementing SMAs was ‘convincing the patients to show up’.28 Patients were reported to be reluctant to take part in a group because they did not want to disclose medical history and health complaints to peers,23 and in one case, this was thought to contribute to SMAs being a short-lived and unsuccessful innovation.27 Some providers described how they spent time identifying patients they thought might be ‘willing to attend’ and did not invite those whom they felt were ‘less suited’ to SMAs, such as those who were hard of hearing, who had limited English speaking skills or who were uncomfortable in a group.31

Role adjustment and uncertainties

NPs experienced difficulties encouraging other staff within the practice to ‘buy in’ and support the SMAs,23 28 reporting it being a ‘hard sell’ to doctors who perceived them as ‘extra work’.28 There was uncertainty and hesitancy among practitioners about SMAs, what was expected of them. Some practitioners reported how SMAs changed the dynamics between patients and provider, with practitioners tending to step back or keep quiet and allow patients to explore and discuss and problem solve between themselves,29 30 but to intervene if misinformation was shared.30 A clinician with no previous experience of group care was initially concerned, recognising that different skills were needed for SMAs. Yet, with minimal coaching, she was ‘surprised at how easy’ it was to sit back, observe and listen rather than having the burden of needing to ‘always know the answers’.16 One study27 reported that there were changes in the power dynamics between professionals particularly between NPs and GPs, as the former often take the lead in delivery of SMAs. One NP reported being irritated when the physician had minimal input during the SMA yet ‘billed for the ten people that were in the group even though the NP had done all of the work, teaching, counselling and the prescriptions’.25

Administrative and resource challenges

The most commonly cited challenge to implementing SMAs was the large number of administrative tasks involved in setting them up,16 19 21–23 25 28 31 with clinicians reporting they can be particularly burdensome for ‘non-medical staff’.22 This included the coordination of schedules for multidisciplinary teamwork,16 21–23 28 access to the technological systems and support staff required to organise SMAs,25 26 identification of participants suitable for SMAs,28 31 difficulties in reminding patients of appointment times, and the preparation of clinical notes and documentation for each SMA. In the context of the US healthcare system, providers also expressed concerns over funding and billing for SMAs,16 18 19 22 27 28 31 with insurance reimbursement issues perceived as a barrier to providing SMAs. Lack of physical space to hold the SMAs was reported as key limitation16 23 27 28 31 as well as insufficient staff to support the adoption, implementation and maintenance of SMAs,16 23 28 with some clinicians giving competing demands on their time as a key challenge to implementation.23 28

Implementation success and sustainability

Skilled facilitator

Practitioners deemed the role of a facilitator to be crucial to the success of SMAs.19 21 28 30 31 They had an important role in making the atmosphere in the group session relaxed and conducive to sharing.31 However, not all clinicians were equipped with group facilitation skills, as one dietician reported having difficulties in managing patients in the group who were ‘overbearing’ and ‘offensive’ rather than supportive of other group members.28 Nurses reported that clinicians who could be flexible and were willing to take a back seat’ were most suited to the SMA model of working.28

Tailored to patient groups

Several SMA studies were designed to target specific patient groups, for example, veterans with low health literacy23 and underserved Spanish speakers.17 Practitioners reported having spent time identifying and designing the SMAs for these specific groups31 and the need to be sensitive to the cultural diversity of group participants.26 For disease-specific SMAs, clinicians acknowledged it was important to take into account the disease stage of the SMA participant, as patients with more disease experience may ‘more adequately influence’ those with less experience.21 Most studies in this review did not describe the process by which patients were selected and invited to attend. An NP believed that the SMAs they tried to implement were unsuccessful because they were not organised and designed in a person-centred way; rather the incentive for the practice was ‘to see a bunch of people all at once and sign off’.25

Leadership, teamwork and communication

Two studies described the importance of having leadership support in order to adopt and implement the innovation23 28 to ensure sufficient time and resources were allocated to the SMAs. A team-based approach and effective communication between members, healthcare practitioners and practice staff were reported to be important for effective implementation, maintenance and sustainability.18 The delivery of care by multidisciplinary teams was also considered a key strength of group appointments.23

Patient and carer view and experiences

A number of subthemes emerged from the patient and carers’ perspectives within overarching themes of ‘benefits of SMAs’ and ‘barriers to SMA attendance and success’ (see table 4).

Benefits of SMAs

Peer support

Most patients described feeling supported by others in the group,16 19 21 22 27–29 feeling that ‘they were not the only one’ with their condition and enjoyed having a safe environment in which to share their experiences and feelings.16 Carers valued the group sessions reporting the additional support they received from being able to share with others in their situation.16

Vicarious learning and collective problem solving

Patients described learning more about their condition, disease progression and treatment options by listening to the lived experiences of others and observing and engaging with other individuals at different stages of their disease.17 27 Being able to ask multiple questions and hearing answers to questions they had not thought to ask were very beneficial.19 25 27 They more readily absorbed/listened more closely to health-related information from peers than from the clinician20 24 30 because they knew they had experienced it themselves. Hearing the experiences of others helped overcome feelings of isolation and provided patients with reassurance in their ability to self-manage.19 Support for SMAs was particularly strong from those with previous health-related group experience.21 Conversely, however, it was reported that some patients did not want to attend any further SMAs because they did not want to talk about their health concerns or listen to other people’s concerns in a group.31

Motivation for self-management

Patients reported feeling more motivated to self-manage their condition(s)17 18 20 and accountable to others in the group to adhere to medication26 and achieve goals that they set themselves.18 28 29 32 Veterans reported that they were using less medication following the group session and were better able to self-manage their condition.20 Similarly, carers reported that their children had learnt skills to manage their ADHD better.16

Safe environment to share

Some patients reported feeling anxious prior to attending SMAs and ashamed of how they had been controlling their condition. However, once they had attended the SMA, they found the session a safe environment in which to share and face their fears, and they had developed greater trust in their health practitioner.29 32 Another study reported that some patients felt the group environment was more relaxed and enjoyable than one-to-one appointments, as ‘there is a certain level of anonymity in a group setting’.29 It was widely reported that patients were satisfied with the care they received during the group sessions.16 19 22 24 26 29 32

Barriers to SMA attendance and success

Some studies reported that patients expressed dislike or lack of interest in group appointments.19 23 Some patients also expressed reservations about sharing personal information and about confidentiality prior to attending,19 21 23 33 especially in smaller communities21; however, this was not a concern after attending the group session.19 In the study of video SMAs,26 some patients reported negative experiences including that the SMA was too big (even though there were only four to six patients per SMA), and there was poor control of group dynamics, but this might have been specific to the remote delivery. It was recognised that a skilled facilitator improved enjoyment and engagement,24 and how providers communicate and interact with patients during the appointment can affect their experience.20 Others found it difficult to relate to other group members33 or did not want to talk about their issues, nor hear other patients’ issues in a group.31 Some patients reported they would have liked more individual time with the clinician26 33 or to have seen their own doctor.21 32 Barriers to attendance included scheduling conflicts with other commitments18 and transportation or parking issues.28

Discussion

This systematic review has identified a detailed literature, primarily from North America, that provides rich accounts of practitioners involved in the delivery SMAs. While most studies included patient perspectives, the richness of the supporting data varied between studies and overall was lower compared with practitioner perspectives. The patient quotes reported to support author interpretation were short and few in some studies, and often demographic information was missing, limiting the readers’ ability to judge the transferability of the findings. There was notably less comparable evidence examining carer perspectives. The experiences of some minority ethnic and indigenous groups were represented, thus offering insights into the acceptability of SMAs for these patient groups. The systematic search and selection measures enabled the identification and synthesis of data, which have brought to light several additional challenges to implementation.

Most practitioners and patients with experience of SMAs regarded them positively and reported several advantages compared with one-to-one appointments. GPs and NPs with SMA experience reported that they enjoyed the sessions, with several reporting they helped overcome the repetition fatigue often associated with traditional consultations. Practitioners also perceived SMAs could be a more efficient and effective way of delivering care. Most patients valued the provision of peer support and reported that being able to share and learn from each other helped improve their self-confidence and provided motivation to reach their goals. However, this experience was not shared by all patients, with some reporting that they were unable to relate to others in their group or that they felt others in the group talked too much. This highlights the need for effective facilitation and careful patient selection in order for SMAs to be successful.

Some practitioners reported difficulties in recruiting patients and garnering support for the delivery of SMAs from other practice colleagues. Notable barriers to SMA implementation included insufficient staff, time and resources to set up and run SMAs. Practitioners were concerned that patients would be reluctant to participate in a group appointment due to low motivation, confidentiality concerns and preference for 1:1 appointments. Some patients also expressed reservations about the group setting due to confidentiality concerns and desire for more time to discuss individual needs.

The positive experiences and perceived benefits of SMAs reported by practitioners and patients in this review corroborate those reported previously,4 10 which suggests SMAs may offer advantages in primary care similar to those in other healthcare settings. However, studies included in this review may be subject to reporting bias due to a focus on attendees rather than those who declined SMAs.4 10 11 Staff and facility inadequacies, patient participation and attendance, group dynamic incompatibilities and cost–benefit concerns have been listed as barriers to implementation previously.9 11 Our review of qualitative evidence provides additional, deeper insights into barriers linked to organisational culture. We found practitioner reports of difficulties in gaining support from colleagues in the wider practice, including managerial staff, some of whom expressed negative attitudes towards SMAs. Furthermore, SMAs involving multidisciplinary teams appear to challenge the traditional hierarchal role of practitioners in primary care, which leads to improved collegiality in some cases and frustration in others. This suggests that clear guidance and expectations around SMAs may not have been effectively communicated within practices. Our review has also highlighted that SMAs appear to be most successful when practitioners have designed and prepared SMAs for particular patient groups, and this work is reported to be resource and time intensive. Practitioners report mixed views about the efficiency of SMAs compared with 1:1 appointments in light of the time and resources to set them up, which requires further exploration.

Limitations

Although the quality of included studies was generally good, most of the healthcare professionals were GPs and NPs, which may limit the generalisability of our findings to other healthcare professionals in primary care such as pharmacists, physiotherapists and dieticians, etc. Few studies provided rich detailed accounts of patient and carers; thus, insights offered from the literature are limited. While PPI members were involved throughout this review, we did not involve nor conduct member checking with practitioners. This would have helped to strengthen the credibility of the review findings. Given that many of the patients were recruited immediately after the SMAs, it is possible that patients with negative SMA experiences or those who declined to participate may be missed; therefore, the sample may be biased.4 10 11 Similarly, only two studies included the perspectives of practitioners not implementing SMAs; therefore, other perceived barriers may not have been captured. Furthermore, the lack of researcher reflexivity reported in the studies highlighted a potential source of bias; those involved in developing or delivering SMAs could have influenced participants’ responses. This may help explain the discrepancy between providers telling researchers that patients were hesitant to attend SMAs, while the latter reported a great deal of enthusiasm. As most studies are from North America, it is unclear whether some barriers, such as payment/insurance reimbursement concerns, are applicable in other global healthcare systems. Limited and inconsistent reporting of study participant demographic information limited our understanding as to whether patient experiences and perspectives differ by long-term condition or other personal characteristics. None of the studies reported differences in patient perspectives based on gender, age ethnicity or cultural group. Similarly, the amount of detail reported about the SMA itself in terms of format, staffing, duration and mode of delivery was limited. It is possible that this underpins some of the differences in experiences of patients and practitioners reported in the studies. In addition, it is unclear whether patient willingness to attend SMAs is sustainable over time due to limited study period and follow-ups.

Most studies in this review reported SMAs designed to support patients with diabetes. Only a limited number of studies reported on other long-term conditions, yet the perceived benefits and experiences reported in mixed-condition studies were similar and do not appear to be condition-specific. Furthermore, only five studies explicitly stated that some SMA participants had multimorbidity. Thus, there was insufficient information reported to understand the acceptability of attending group appointments with individuals who have different combinations of conditions. Further exploration of the use and experience of SMAs for patients with multimorbidity is needed.

Conclusion

Practitioner, patient and carer experiences of SMAs delivered in primary care have generally been positive, with benefits to both practice and patients reported. However, there is not enough evidence to show if views and experiences vary by staff involved, medical condition and/or patient characteristics. Further research is needed to better understand which groups of patients and practitioners should be brought together in an SMA for best effect. Whether SMAs for single conditions adequately meet the care needs of patients with multimorbidity also needs further exploration. This will help to inform guidance for practitioners on how best to identify and recruit patients to SMAs, rather than identifying and inviting patients based on personal judgements, which could have implications for health inequalities. Having identified a number of barriers and facilitators, we found that policies and guidance need to be developed and effectively communicated across and within practices on how best to implement and evaluate SMAs in practice. This, in turn, may help to improve staff expectations and overcome the hesitancy regarding SMA approaches. Additional resources may be needed to deliver SMAs such as additional administrative support, further training, compatible IT systems and physical space; a needs assessment may be required at practice level. The views of healthcare practitioners not currently delivering SMAs are required to ensure all barriers have been comprehensively explored. This is important to fully understand what interventions might be necessary to support the widespread adoption and implementation of SMAs in primary care. In addition, given the increased use of video consultations due to the outbreak of COVID-19, further exploration as to the acceptability and feasibility of SMAs delivered via videoconference is warranted.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. As this study is a systematic review, all data reported has been previously published and is in the public domain.

Ethics statements

Patient consent for publication

Acknowledgments

We thank the PRU BehSci Public Patient Involvement group and Jan Lecouturier for providing comments on the manuscript prior to submission. Professor Kaner is supported via an NIHR Senior Investigator award.

References

Supplementary materials

Footnotes

  • Contributors EK, KJ and HM designed the study. MYT and KJ undertook the searches. FG, MYT, KJ, OO, EK and AOD carried out the screening. FG, MYT, KJ and HM carried out the data extraction and analysis. All authors contributed to the interpretation. FG wrote the manuscript that all authors contributed to and approved.

  • Funding This paper is independent research commissioned and funded by the NIHR PRU in Behavioural Science (award: PR-PRU-1217-20501) and Research Capability Funding from North East Commissioning Support (award: N/A).

  • Disclaimer The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research, the Department of Health and Social Care or its arm's length bodies, and other government departments. The funders had no role in the design of the study, collection, analysis or interpretation of data, or in the writing of the manuscript.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.